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Lesion severity and treatment complexity are associated with outcome after percutaneous infra-inguinal intervention
Brian G DeRubertis1, Matthew Pierce, Rabih A Chaer
1Division of Vascular Surgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, NY 10021, USA.
Insights
Percutaneous revascularization for limb-threatening ischemia shows higher initial failure rates due to complex lesions. However, secondary patency and limb salvage remain unaffected, suggesting percutaneous treatment is viable with potential for higher re-intervention needs.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Percutaneous revascularization is increasingly used for lower extremity ischemia.
- Patients with limb-threatening ischemia face higher failure risks, but underlying reasons are not fully understood.
Purpose of the Study:
- To analyze factors associated with percutaneous treatment failure in lower extremity ischemia.
- To focus on lesion characteristics and treatment complexity in relation to treatment outcomes.
Main Methods:
- Retrospective review of percutaneous infra-inguinal interventions for peripheral occlusive disease (2002-2005).
- Lesion assessment using angiography and TransAtlantic InterSociety Consensus (TASC) criteria.
- Kaplan-Meier analysis for patency and Cox-regression for significant factors.
Main Results:
- Limb-threatening ischemia was linked to higher primary and secondary patency failure.
- Increased TASC grade, multilevel interventions, tibial interventions, and reduced tibial outflow correlated with decreased primary patency.
- Multilevel and tibial interventions were independently associated with primary patency failure.
Conclusions:
- Limb-threatening ischemia patients have higher initial failure rates due to complex lesions and treatment difficulty.
- These factors impact primary patency but not secondary patency or limb salvage.
- Percutaneous intervention is a viable primary treatment, but higher re-intervention rates and potential need for surgical bypass should be considered.
Objectives:
Percutaneous revascularization has become increasingly utilized for the treatment of lower extremity ischemia. Patients with limb-threat have been shown to be at increased risk of failure, although the reasons for this remain unclear. This study analyzed factors associated with percutaneous treatment failure, focusing specifically on lesion characteristics and treatment complexity.
Methods:
We retrospectively reviewed percutaneous infra-inguinal interventions performed for peripheral occlusive disease between 2002 and 2005 using a prospectively maintained database. Lesion characteristics were assessed by angiography, and lesions were graded according to the TransAtlantic InterSociety Consensus (TASC) criteria. Patency was expressed by Kaplan-Meier method and compared by log-rank analysis. Multivariate Cox-regression analysis was used to assess significant factors on univariate analysis. Mean follow-up was 11.8 months.
Results:
A total of 324 interventions for claudication (55.8%), rest pain (18.4%), or tissue loss (25.8%) were analyzed, including 284 primary interventions and 40 re-interventions in 258 patients (mean age 72.1 +/- 10 years, 51.0% male). TASC lesion grades included: A (4.9%), B (29.3%), C (37.7%), and D (28.1%). Isolated single-level interventions (femoral, popliteal, or tibial) were performed in 38.9%, while two-level interventions were performed in 46.2% and three-level interventions in 14.9%. Overall primary patency (+/- SD) at 6, 12, and 18 months was 87 +/- 2%, 66 +/- 2% and 59 +/- 4%, respectively. Secondary patency at 6, 12, and 18 months was 89 +/- 2%, 76 +/- 3%, and 69 +/- 5%. One-year limb salvage rate (limb-threat patients) was 85 +/- 3%. Limb-threatening ischemia as the indication for intervention was most highly associated with failure of both primary and secondary patency and was associated with four indicators of lesion severity and treatment complexity, including increasing TASC grade, multilevel intervention, tibial intervention, and reduced tibial outflow. One-year primary patency was inversely correlated with TASC severity (TASC A-C: 67 +/- 6%, D: 61 +/- 4%; P < .05), multilevel intervention (76 +/- 5% and 49 +/- 9% for single vs multilevel, P = .002), distal interventions (74 +/- 5% and 57 +/- 7% for femoral vs tibial, P < .05), and decreased tibial runoff (83 +/- 6% and 52 +/- 6% for three- vs < three-vessels, P < .02). No differences in secondary patency or limb-salvage rates existed for these lesion- and treatment-related variables. Multilevel intervention and tibial intervention remained significant independently associated with primary patency on multivariate analysis.
Conclusions:
Patients with limb-threatening ischemia are at increased risk of initial failure compared with claudicants, likely as a result of the increased prevalence of advanced lesion severity and treatment complexity, which are associated with decreased primary patency. However, this finding did not extend to secondary patency or limb-salvage in the overall patient population. Although additional studies with longer follow-up are needed, these findings argue that percutaneous intervention may still be considered as a primary treatment modality with the understanding that these patients may have higher re-intervention rates and may ultimately require salvage open surgical bypass for persistent failures of percutaneous therapy.
